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FACILITY NAME: <br /> FACILITY ADDRESS: 26C ' 1'i to i L) ,Mf(A TANK ID # ,1333 Cxx� <br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD <br /> This form is to be returned to San Joaquin Local Health District within 30 days of <br /> acceptance of tank(s) by disposal or recycling facility. The holder of the permit <br /> with number noted above is responsible for ensuring that this form is completed and <br /> returned. <br /> w x x x x x x w w w w x x x x x x x x w x w x w x w w x x w x x w w w SECfICN 1 - <br /> To be filled out by tank removal contractor: <br /> Tank Removal Contractor: <br /> Address: Phone M <br /> Zip <br /> Date Tanks Removed No. of Tanks <br /> x w x x x x x x x x x x x x x x x x x x x x x x t x w x x x t x x x x <br /> SECTION 2 - To be filled out by contractor "decontaminating tanks)": <br /> Tank "Decontamination" Contractor <br /> Address Phoney <br /> Zip <br /> Authorized representative of contractor certifies by signing below that tank(s) <br /> has(have) been decontaminated in an approved manner as may be regulated by <br /> Department of Health Services. <br /> SIGNATURE AND TITLE <br /> x x x w x x x x x x x x w x w x x x x x x x x x x x x x x x x x x x w <br /> SECTION 3 - To be filled out and signed by an authorized representative of the <br /> treatment, storage, or disposal facility accepting tank(s). <br /> Facility Name <br /> Address Phone# <br /> Zip <br /> Date Tanks Received No. of Tanks <br /> ALMHO2IZED SIGNATURE AND TITLE <br /> x x * x * * * x x * x x w x w x x x x x x x x w x x x x x x x x x x x <br /> MAILING INSTRUCTIONS: Fold in half and staple. Affix proper postage. <br /> EH N XX WP\TRACSHT.LET <br />